Bronson Methodist Hospital

All Charges

Charge

Type

Setting

Price

PR CYSTOTOMY/CYSTOSTOMY FULG&/INSJ RADACT MATRL

Professional

Both

$2,402.00

Service Code	HCPCS 51020
Min. Negotiated Rate	$301.61
Max. Negotiated Rate	$3,049.88
Rate for Payer: Aetna Commercial	$601.20
Rate for Payer: BCBS Complete	$316.69
Rate for Payer: BCBS Trust/PPO	$3,049.88
Rate for Payer: Cash Price	$1,921.60
Rate for Payer: Cash Price	$1,921.60
Rate for Payer: Meridian Medicaid	$316.69
Rate for Payer: Priority Health Choice Medicaid	$301.61
Rate for Payer: Priority Health Cigna Priority Health	$1,681.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$752.72
Rate for Payer: Priority Health Narrow Network	$752.72
Rate for Payer: Priority Health SBD	$752.72
Rate for Payer: UMR Bronson Commercial	$1,104.92

PR CYSTOTOMY EXCISE BLADDER DIVERTICULUM 1/MULTIPLE

Professional

Both

$1,963.00

Service Code	HCPCS 51525
Min. Negotiated Rate	$544.85
Max. Negotiated Rate	$3,181.95
Rate for Payer: Aetna Commercial	$1,103.89
Rate for Payer: BCBS Complete	$572.09
Rate for Payer: BCBS Trust/PPO	$3,181.95
Rate for Payer: Cash Price	$1,570.40
Rate for Payer: Cash Price	$1,570.40
Rate for Payer: Meridian Medicaid	$572.09
Rate for Payer: Priority Health Choice Medicaid	$544.85
Rate for Payer: Priority Health Cigna Priority Health	$1,374.10
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,370.35
Rate for Payer: Priority Health Narrow Network	$1,370.35
Rate for Payer: Priority Health SBD	$1,370.35
Rate for Payer: UMR Bronson Commercial	$902.98

PR CYSTOTOMY EXCISE/INCISE/REPAIR URETEROCELE

Professional

Both

$1,695.00

Service Code	HCPCS 51535
Min. Negotiated Rate	$495.86
Max. Negotiated Rate	$3,177.20
Rate for Payer: Aetna Commercial	$1,001.20
Rate for Payer: BCBS Complete	$520.65
Rate for Payer: BCBS Trust/PPO	$3,177.20
Rate for Payer: Cash Price	$1,356.00
Rate for Payer: Cash Price	$1,356.00
Rate for Payer: Meridian Medicaid	$520.65
Rate for Payer: Priority Health Choice Medicaid	$495.86
Rate for Payer: Priority Health Cigna Priority Health	$1,186.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,243.36
Rate for Payer: Priority Health Narrow Network	$1,243.36
Rate for Payer: Priority Health SBD	$1,243.36
Rate for Payer: UMR Bronson Commercial	$779.70

PR CYSTOTOMY EXCISION BLADDER TUMOR

Professional

Both

$1,363.00

Service Code	HCPCS 51530
Min. Negotiated Rate	$489.90
Max. Negotiated Rate	$2,404.29
Rate for Payer: Aetna Commercial	$988.36
Rate for Payer: BCBS Complete	$514.40
Rate for Payer: BCBS Trust/PPO	$2,404.29
Rate for Payer: Cash Price	$1,090.40
Rate for Payer: Cash Price	$1,090.40
Rate for Payer: Meridian Medicaid	$514.40
Rate for Payer: Priority Health Choice Medicaid	$489.90
Rate for Payer: Priority Health Cigna Priority Health	$954.10
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,227.70
Rate for Payer: Priority Health Narrow Network	$1,227.70
Rate for Payer: Priority Health SBD	$1,227.70
Rate for Payer: UMR Bronson Commercial	$626.98

PR CYSTOTOMY SIMPLE EXCISION VESICAL NECK

Professional

Both

$1,204.00

Service Code	HCPCS 51520
Min. Negotiated Rate	$380.42
Max. Negotiated Rate	$3,020.82
Rate for Payer: Aetna Commercial	$763.07
Rate for Payer: BCBS Complete	$399.44
Rate for Payer: BCBS Trust/PPO	$3,020.82
Rate for Payer: Cash Price	$963.20
Rate for Payer: Cash Price	$963.20
Rate for Payer: Meridian Medicaid	$399.44
Rate for Payer: Priority Health Choice Medicaid	$380.42
Rate for Payer: Priority Health Cigna Priority Health	$842.80
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$952.11
Rate for Payer: Priority Health Narrow Network	$952.11
Rate for Payer: Priority Health SBD	$952.11
Rate for Payer: UMR Bronson Commercial	$553.84

PR CYSTOTOMY W/CALCULUS BASKET XTRJ&/FRAGMENTATIO

Professional

Both

$1,930.00

Service Code	HCPCS 51065
Min. Negotiated Rate	$370.83
Max. Negotiated Rate	$2,864.97
Rate for Payer: Aetna Commercial	$743.33
Rate for Payer: BCBS Complete	$389.37
Rate for Payer: BCBS Trust/PPO	$2,864.97
Rate for Payer: Cash Price	$1,544.00
Rate for Payer: Cash Price	$1,544.00
Rate for Payer: Meridian Medicaid	$389.37
Rate for Payer: Priority Health Choice Medicaid	$370.83
Rate for Payer: Priority Health Cigna Priority Health	$1,351.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$927.79
Rate for Payer: Priority Health Narrow Network	$927.79
Rate for Payer: Priority Health SBD	$927.79
Rate for Payer: UMR Bronson Commercial	$887.80

PR CYSTOTOMY W/INSJ URETERAL CATH/STENT SPX

Professional

Both

$1,012.00

Service Code	HCPCS 51045
Min. Negotiated Rate	$319.07
Max. Negotiated Rate	$3,133.88
Rate for Payer: Aetna Commercial	$645.19
Rate for Payer: BCBS Complete	$335.02
Rate for Payer: BCBS Trust/PPO	$3,133.88
Rate for Payer: Cash Price	$809.60
Rate for Payer: Cash Price	$809.60
Rate for Payer: Meridian Medicaid	$335.02
Rate for Payer: Priority Health Choice Medicaid	$319.07
Rate for Payer: Priority Health Cigna Priority Health	$708.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$805.13
Rate for Payer: Priority Health Narrow Network	$805.13
Rate for Payer: Priority Health SBD	$805.13
Rate for Payer: UMR Bronson Commercial	$465.52

PR CYSTO/URETERO W/LITHOTRIPSY &INDWELL STENT INSRT

Professional

Both

$831.00

Service Code	HCPCS 52356
Min. Negotiated Rate	$260.71
Max. Negotiated Rate	$654.37
Rate for Payer: Aetna Commercial	$532.71
Rate for Payer: BCBS Complete	$273.75
Rate for Payer: BCBS Trust/PPO	$478.11
Rate for Payer: Cash Price	$664.80
Rate for Payer: Cash Price	$664.80
Rate for Payer: Meridian Medicaid	$273.75
Rate for Payer: Priority Health Choice Medicaid	$260.71
Rate for Payer: Priority Health Cigna Priority Health	$581.70
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$654.37
Rate for Payer: Priority Health Narrow Network	$654.37
Rate for Payer: Priority Health SBD	$654.37
Rate for Payer: UMR Bronson Commercial	$382.26

PR CYSTOURETHROSCOPY

Professional

Both

$461.00

Service Code	HCPCS 52000
Min. Negotiated Rate	$50.69
Max. Negotiated Rate	$1,840.07
Rate for Payer: Aetna Commercial	$102.99
Rate for Payer: BCBS Complete	$53.22
Rate for Payer: BCBS Trust/PPO	$1,840.07
Rate for Payer: Cash Price	$368.80
Rate for Payer: Cash Price	$368.80
Rate for Payer: Meridian Medicaid	$53.22
Rate for Payer: Priority Health Choice Medicaid	$50.69
Rate for Payer: Priority Health Cigna Priority Health	$322.70
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$127.52
Rate for Payer: Priority Health Narrow Network	$127.52
Rate for Payer: Priority Health SBD	$127.52
Rate for Payer: UMR Bronson Commercial	$212.06

PR CYSTOURETHROSCOPY INJ CHEMODENERVATION BLADDER

Professional

Both

$691.00

Service Code	HCPCS 52287
Min. Negotiated Rate	$106.29
Max. Negotiated Rate	$1,222.49
Rate for Payer: Aetna Commercial	$217.02
Rate for Payer: BCBS Complete	$111.60
Rate for Payer: BCBS Trust/PPO	$1,222.49
Rate for Payer: Cash Price	$552.80
Rate for Payer: Cash Price	$552.80
Rate for Payer: Meridian Medicaid	$111.60
Rate for Payer: Priority Health Choice Medicaid	$106.29
Rate for Payer: Priority Health Cigna Priority Health	$483.70
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$268.02
Rate for Payer: Priority Health Narrow Network	$268.02
Rate for Payer: Priority Health SBD	$268.02
Rate for Payer: UMR Bronson Commercial	$317.86

PR CYSTOURETHROSCOPY INSERTION PERM URETHRAL STENT

Professional

Both

$637.00

Service Code	HCPCS 52282
Min. Negotiated Rate	$211.72
Max. Negotiated Rate	$1,714.86
Rate for Payer: Aetna Commercial	$429.33
Rate for Payer: BCBS Complete	$222.31
Rate for Payer: BCBS Trust/PPO	$1,714.86
Rate for Payer: Cash Price	$509.60
Rate for Payer: Cash Price	$509.60
Rate for Payer: Meridian Medicaid	$222.31
Rate for Payer: Priority Health Choice Medicaid	$211.72
Rate for Payer: Priority Health Cigna Priority Health	$445.90
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$530.63
Rate for Payer: Priority Health Narrow Network	$530.63
Rate for Payer: Priority Health SBD	$530.63
Rate for Payer: UMR Bronson Commercial	$293.02

PR CYSTOURETHROSCOPY INSJ RADIOACT SBST W/WOBX/FULG

Professional

Both

$490.00

Service Code	HCPCS 52250
Min. Negotiated Rate	$150.17
Max. Negotiated Rate	$4,966.55
Rate for Payer: Aetna Commercial	$305.69
Rate for Payer: BCBS Complete	$157.68
Rate for Payer: BCBS Trust/PPO	$4,966.55
Rate for Payer: Cash Price	$392.00
Rate for Payer: Cash Price	$392.00
Rate for Payer: Meridian Medicaid	$157.68
Rate for Payer: Priority Health Choice Medicaid	$150.17
Rate for Payer: Priority Health Cigna Priority Health	$343.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$377.71
Rate for Payer: Priority Health Narrow Network	$377.71
Rate for Payer: Priority Health SBD	$377.71
Rate for Payer: UMR Bronson Commercial	$225.40

PR CYSTOURETHROSCOPY TX FEMALE URETHRAL SYNDROME

Professional

Both

$626.00

Service Code	HCPCS 52285
Min. Negotiated Rate	$123.54
Max. Negotiated Rate	$1,483.99
Rate for Payer: Aetna Commercial	$250.61
Rate for Payer: BCBS Complete	$129.72
Rate for Payer: BCBS Trust/PPO	$1,483.99
Rate for Payer: Cash Price	$500.80
Rate for Payer: Cash Price	$500.80
Rate for Payer: Meridian Medicaid	$129.72
Rate for Payer: Priority Health Choice Medicaid	$123.54
Rate for Payer: Priority Health Cigna Priority Health	$438.20
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$309.08
Rate for Payer: Priority Health Narrow Network	$309.08
Rate for Payer: Priority Health SBD	$309.08
Rate for Payer: UMR Bronson Commercial	$287.96

PR CYSTOURETHROSCOPY W/DEST &/RMVL MED BLADDER TUM

Professional

Both

$1,144.00

Service Code	HCPCS 52235
Min. Negotiated Rate	$181.26
Max. Negotiated Rate	$3,767.31
Rate for Payer: Aetna Commercial	$368.99
Rate for Payer: BCBS Complete	$190.32
Rate for Payer: BCBS Trust/PPO	$3,767.31
Rate for Payer: Cash Price	$915.20
Rate for Payer: Cash Price	$915.20
Rate for Payer: Meridian Medicaid	$190.32
Rate for Payer: Priority Health Choice Medicaid	$181.26
Rate for Payer: Priority Health Cigna Priority Health	$800.80
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$454.98
Rate for Payer: Priority Health Narrow Network	$454.98
Rate for Payer: Priority Health SBD	$454.98
Rate for Payer: UMR Bronson Commercial	$526.24

PR CYSTOURETHROSCOPY W/DEST &/RMVL TUMOR LARGE

Professional

Both

$2,199.00

Service Code	HCPCS 52240
Min. Negotiated Rate	$246.02
Max. Negotiated Rate	$4,858.78
Rate for Payer: Aetna Commercial	$501.54
Rate for Payer: BCBS Complete	$258.32
Rate for Payer: BCBS Trust/PPO	$4,858.78
Rate for Payer: Cash Price	$1,759.20
Rate for Payer: Cash Price	$1,759.20
Rate for Payer: Meridian Medicaid	$258.32
Rate for Payer: Priority Health Choice Medicaid	$246.02
Rate for Payer: Priority Health Cigna Priority Health	$1,539.30
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$617.63
Rate for Payer: Priority Health Narrow Network	$617.63
Rate for Payer: Priority Health SBD	$617.63
Rate for Payer: UMR Bronson Commercial	$1,011.54

PR CYSTOURETHROSCOPY W/DIL BLADDER GENERAL ANESTH

Professional

Both

$387.00

Service Code	HCPCS 52260
Min. Negotiated Rate	$132.49
Max. Negotiated Rate	$1,421.13
Rate for Payer: Aetna Commercial	$269.31
Rate for Payer: BCBS Complete	$139.11
Rate for Payer: BCBS Trust/PPO	$1,421.13
Rate for Payer: Cash Price	$309.60
Rate for Payer: Cash Price	$309.60
Rate for Payer: Meridian Medicaid	$139.11
Rate for Payer: Priority Health Choice Medicaid	$132.49
Rate for Payer: Priority Health Cigna Priority Health	$270.90
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$333.39
Rate for Payer: Priority Health Narrow Network	$333.39
Rate for Payer: Priority Health SBD	$333.39
Rate for Payer: UMR Bronson Commercial	$178.02

PR CYSTOURETHROSCOPY W/DIL BLADDER LOCAL ANESTHESIA

Professional

Both

$625.00

Service Code	HCPCS 52265
Min. Negotiated Rate	$102.45
Max. Negotiated Rate	$5,029.94
Rate for Payer: Aetna Commercial	$208.09
Rate for Payer: BCBS Complete	$107.57
Rate for Payer: BCBS Trust/PPO	$5,029.94
Rate for Payer: Cash Price	$500.00
Rate for Payer: Cash Price	$500.00
Rate for Payer: Meridian Medicaid	$107.57
Rate for Payer: Priority Health Choice Medicaid	$102.45
Rate for Payer: Priority Health Cigna Priority Health	$437.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$257.21
Rate for Payer: Priority Health Narrow Network	$257.21
Rate for Payer: Priority Health SBD	$257.21
Rate for Payer: UMR Bronson Commercial	$287.50

PR CYSTOURETHROSCOPY W/INTERNAL URETHROTOMY

Professional

Both

$1,099.00

Service Code	HCPCS 52276
Min. Negotiated Rate	$165.93
Max. Negotiated Rate	$2,759.84
Rate for Payer: Aetna Commercial	$338.51
Rate for Payer: BCBS Complete	$174.23
Rate for Payer: BCBS Trust/PPO	$2,759.84
Rate for Payer: Cash Price	$879.20
Rate for Payer: Cash Price	$879.20
Rate for Payer: Meridian Medicaid	$174.23
Rate for Payer: Priority Health Choice Medicaid	$165.93
Rate for Payer: Priority Health Cigna Priority Health	$769.30
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$416.62
Rate for Payer: Priority Health Narrow Network	$416.62
Rate for Payer: Priority Health SBD	$416.62
Rate for Payer: UMR Bronson Commercial	$505.54

PR CYSTOURETHROSCOPY W/INTERNAL URETHROTOMY FEMALE

Professional

Both

$702.00

Service Code	HCPCS 52270
Min. Negotiated Rate	$114.17
Max. Negotiated Rate	$4,237.49
Rate for Payer: Aetna Commercial	$233.02
Rate for Payer: BCBS Complete	$119.88
Rate for Payer: BCBS Trust/PPO	$4,237.49
Rate for Payer: Cash Price	$561.60
Rate for Payer: Cash Price	$561.60
Rate for Payer: Meridian Medicaid	$119.88
Rate for Payer: Priority Health Choice Medicaid	$114.17
Rate for Payer: Priority Health Cigna Priority Health	$491.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$286.39
Rate for Payer: Priority Health Narrow Network	$286.39
Rate for Payer: Priority Health SBD	$286.39
Rate for Payer: UMR Bronson Commercial	$322.92

PR CYSTOURETHROSCOPY W/INTERNAL URETHROTOMY MALE

Professional

Both

$958.00

Service Code	HCPCS 52275
Min. Negotiated Rate	$155.92
Max. Negotiated Rate	$5,563.53
Rate for Payer: Aetna Commercial	$317.31
Rate for Payer: BCBS Complete	$163.72
Rate for Payer: BCBS Trust/PPO	$5,563.53
Rate for Payer: Cash Price	$766.40
Rate for Payer: Cash Price	$766.40
Rate for Payer: Meridian Medicaid	$163.72
Rate for Payer: Priority Health Choice Medicaid	$155.92
Rate for Payer: Priority Health Cigna Priority Health	$670.60
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$391.21
Rate for Payer: Priority Health Narrow Network	$391.21
Rate for Payer: Priority Health SBD	$391.21
Rate for Payer: UMR Bronson Commercial	$440.68

PR CYSTOURETHROSCOPY WITH BIOPSY

Professional

Both

$733.00

Service Code	HCPCS 52204
Min. Negotiated Rate	$89.25
Max. Negotiated Rate	$1,981.65
Rate for Payer: Aetna Commercial	$180.40
Rate for Payer: BCBS Complete	$93.71
Rate for Payer: BCBS Trust/PPO	$1,981.65
Rate for Payer: Cash Price	$586.40
Rate for Payer: Cash Price	$586.40
Rate for Payer: Meridian Medicaid	$93.71
Rate for Payer: Priority Health Choice Medicaid	$89.25
Rate for Payer: Priority Health Cigna Priority Health	$513.10
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$222.63
Rate for Payer: Priority Health Narrow Network	$222.63
Rate for Payer: Priority Health SBD	$222.63
Rate for Payer: UMR Bronson Commercial	$337.18

PR CYSTOURETHROSCOPY W/RMVL URETERAL CALCULUS

Professional

Both

$1,398.00

Service Code	HCPCS 52320
Min. Negotiated Rate	$154.43
Max. Negotiated Rate	$978.60
Rate for Payer: Aetna Commercial	$315.24
Rate for Payer: BCBS Complete	$162.15
Rate for Payer: BCBS Trust/PPO	$454.34
Rate for Payer: Cash Price	$1,118.40
Rate for Payer: Cash Price	$1,118.40
Rate for Payer: Meridian Medicaid	$162.15
Rate for Payer: Priority Health Choice Medicaid	$154.43
Rate for Payer: Priority Health Cigna Priority Health	$978.60
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$387.98
Rate for Payer: Priority Health Narrow Network	$387.98
Rate for Payer: Priority Health SBD	$387.98
Rate for Payer: UMR Bronson Commercial	$643.08

PR CYSTOURETHROSCOPY W/STEROID INJECTION STRICTURE

Professional

Both

$408.00

Service Code	HCPCS 52283
Min. Negotiated Rate	$126.74
Max. Negotiated Rate	$606.49
Rate for Payer: Aetna Commercial	$258.19
Rate for Payer: BCBS Complete	$133.08
Rate for Payer: BCBS Trust/PPO	$606.49
Rate for Payer: Cash Price	$326.40
Rate for Payer: Cash Price	$326.40
Rate for Payer: Meridian Medicaid	$133.08
Rate for Payer: Priority Health Choice Medicaid	$126.74
Rate for Payer: Priority Health Cigna Priority Health	$285.60
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$317.74
Rate for Payer: Priority Health Narrow Network	$317.74
Rate for Payer: Priority Health SBD	$317.74
Rate for Payer: UMR Bronson Commercial	$187.68

PR CYSTOURETHROSCOPY W/URETERAL MEATOTOMY UNI/BI

Professional

Both

$465.00

Service Code	HCPCS 52290
Min. Negotiated Rate	$152.93
Max. Negotiated Rate	$1,479.24
Rate for Payer: Aetna Commercial	$311.87
Rate for Payer: BCBS Complete	$160.58
Rate for Payer: BCBS Trust/PPO	$1,479.24
Rate for Payer: Cash Price	$372.00
Rate for Payer: Cash Price	$372.00
Rate for Payer: Meridian Medicaid	$160.58
Rate for Payer: Priority Health Choice Medicaid	$152.93
Rate for Payer: Priority Health Cigna Priority Health	$325.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$384.74
Rate for Payer: Priority Health Narrow Network	$384.74
Rate for Payer: Priority Health SBD	$384.74
Rate for Payer: UMR Bronson Commercial	$213.90

PR CYSTO W/COMPLEX REMOVAL STONE & STENT

Professional

Both

$793.00

Service Code	HCPCS 52315
Min. Negotiated Rate	$172.32
Max. Negotiated Rate	$1,188.68
Rate for Payer: Aetna Commercial	$351.84
Rate for Payer: BCBS Complete	$180.94
Rate for Payer: BCBS Trust/PPO	$1,188.68
Rate for Payer: Cash Price	$634.40
Rate for Payer: Cash Price	$634.40
Rate for Payer: Meridian Medicaid	$180.94
Rate for Payer: Priority Health Choice Medicaid	$172.32
Rate for Payer: Priority Health Cigna Priority Health	$555.10
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$433.90
Rate for Payer: Priority Health Narrow Network	$433.90
Rate for Payer: Priority Health SBD	$433.90
Rate for Payer: UMR Bronson Commercial	$364.78

Know your out-of-pocket cost for care.

All Charges